This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the second three descriptors in the Drug Therapies & Medications: Symptom Control domain, to help you assess your or your relative’s “level of need” in this important domain.
Catch up on parts one to seventeen below!
Get Help Breaking Down The Decision Support Tool: An Overview
Get Help Breaking Down the Decision Support Tool: Breathing Part 1
Get Help Breaking Down the Decision Support Tool: Breathing Part 2
Get Help Breaking Down the Decision Support Tool: Nutrition Part 1
Get Help Breaking Down the Decision Support Tool: Nutrition Part 2
Get Help Breaking Down the Decision Support Tool: Continence
Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 1
Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 2
Get Help Breaking Down the Decision Support Tool: Mobility, Part 1
Get Help Breaking Down the Decision Support Tool: Mobility, Part 2
Get Help Breaking Down the Decision Support Tool: Communication
Get Help Breaking Down the Decision Support Tool: Psychological & Emotional Needs
Get Help Breaking Down the Decision Support Tool: Cognition, Part 1
Get Help Breaking Down the Decision Support Tool: Cognition, Part 2
Get Help Breaking Down the Decision Support Tool: Behaviour, Part 1
Get Help Breaking Down the Decision Support Tool: Behaviour, Part 2
Recently, we looked at the first three descriptors in the Drug Therapies & Medications: Symptom Control domain – ‘No Needs’, ‘Low’ and ‘Moderate’ needs. This week we’ll examine the descriptors for ‘High’, ‘Severe’ and ‘Priority’ needs in this important domain.
The following clinical factors are relevant to the assessment of ‘High’, ‘Severe’ or ‘Priority’ needs in this domain:
- What symptoms need to be controlled?
- What medications are prescribed?
- Is any clinical judgment required in deciding to administer medications?
- Are any as-required (PRN) medications required?
- Are the medications effective in controlling symptoms?
- Does the person experience pain? How severe?
- Does pain impact on the delivery of care?
- Can pain be controlled?
- Are any specialists involved in prescribing and overseeing the medication regime?
- Is the person compliant with their medication regime?
- If not, is there a risk of relapse or serious injury if the medication is missed?
Now we’ve outlined the type of things the Multi-Disciplinary Team (MDT) will be considering in this domain, let’s take a look at the descriptors for the ‘High, ‘Severe’ and ‘Priority’ levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors might be applied at your or your relative’s assessment.
IMPORTANT –This domain is often referred to simply as “medications”. This misses the most important aspect to consider when assessing needs in this domain: symptom control. Needs in this domain are determined by the type of mediations required to manage symptoms, the route of administration and the effectiveness of symptom management. Symptoms that are well-controlled with medication (i.e., non-problematic to manage) will not exceed the “High” level of need.
HIGH
Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for the task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non-problematic to manage.
OR Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care. |
Key FactorsComplex medication regime PRN (as required) medications, requiring clinical judgement Symptoms are usually effectively controlled Pain, or other symptoms, which affects the delivery of care (e.g., repositioning) |
CASE STUDY – HIGH
Medications MAR Chart
Aspirin 75mg one to be taken each day after food
Lansoprazole 15mg one to be taken in the morning
Morphine sulphate 10mg/5mg PRN 2.5mls up to 4 times a day
Paracetamol 1 tablet 4 x day. 1 paracetamol to be taken at each visit
Macrogol oral powder- one sachet three times a day.
Calcichew d3 forte one to be taken daily
Donepezil 10mg take one each morning
Docusate sodium 100mg one tablet twice per day
Ibandronic acid 150mg 5th of every month 1 tablet 1 hour before food.
Mrs. X is prescribed a variety of medications, which are administered to her by the registered nurse.
The home reports Mrs. X is compliant with medications, although she requires assistance to take them. She is able to place the medications in her mouth once they are in her hand; staff assist her with a drink.
Mrs. X is prescribed PRN Oramorph which the nurse administers as required. A total of 23 doses of Oramorph were administered in the last month as per her medication charts. Mrs. X has long-standing back pain and takes regular paracetamol: it appears she only has a 500mg dose four times a day; the reasons for this are unclear. She was previously prescribed codeine but this was stopped due to constipation. Mrs X also uses a hot water bottle to help her back pain. There is evidence that when Oramorph was given regularly, this caused Mrs X to feel unwell; it was reviewed, therefore, and is now only to be given as required. This regime appears to be effective in controlling pain symptoms without adverse side effects.
Mrs. X presents with a ‘HIGH’ level of need as she requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for the task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non-problematic to manage.
OR
Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care.
SEVERE
Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. Even with such monitoring the condition is usually problematic to manage.
OR Severe recurrent or constant pain which is not responding to treatment. OR Non-compliance with medication, placing them at severe risk of relapse. |
Key FactorsComplex medication regime PRN (as required) medications, requiring clinical judgement Symptoms not effectively controlled despite medications Fluctuations in condition Specialist oversight (e.g., consultant) Severe pain which is not readily controlled by analgesia Refusals of critical medications – e.g., insulin |
CASE STUDY – SEVERE
Mrs X has a diagnosis of Parkinson’s disease and remains under the care of the Neurologist. There are significant difficulties in balancing her physical and psychological symptoms. She is reliant on carers for the administration of her medication regime, in accordance with the Neurologist’s instructions. Mrs X is fully compliant and is aware of when she requires additional Madopar. Mrs X is able to indicate pain and discomfort and request appropriate medication for symptom relief.
Mrs X has a number of medical conditions that require oversight:
- Parkinson’s disease and secondary to this experiences stiffness, and wearing off of her anti-Parkinson’s medication resulting in “freezing”. Additionally, Mrs X experiences hallucinations, Paranoia and anxiety. She is prescribed PRN Lorazepam to reduce these symptoms
- Postural Hypotension treated with Fludrocortisone
- History of Pulmonary Embolism and DVT requiring Warfarin and INR monitoring
Following an increase in symptoms, the nursing home has recently discontinued its usual care plans for Mrs. X, owing to the “rapid changes” in her condition. It has now implemented a holistic plan to be reviewed on a monthly basis.
Routine Madopar was discontinued on the advice of the Parkinson’s Nurse Specialist in early-May, as it was believed to be worsening symptoms of hallucinations and distress; Madopar continued to be prescribed PRN. Initially, an improvement in Mrs. X’s psychological state was noted. However, she had been urgently referred to the Specialist Parkinson’s Consultant, as she was once again suffering “severe hallucinations”. The Consultant described being between a “rock and a hard place” in terms of trying to balance Mrs. X’s psychological and physical needs. Mrs. X’s condition remains problematic to manage.
Mrs. X presents with a ‘SEVERE’ level of need as she requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. Even with such monitoring the condition is usually problematic to manage.
PRIORITY
Has a drug regime that requires daily monitoring by a registered nurse to ensure effective symptom and pain management associated with a rapidly changing and/or deteriorating condition.
OR Unremitting and overwhelming pain despite all efforts to control pain effectively. |
Key FactorsEnd of life medications, patient rapidly deteriorating and symptoms difficult to control Severe, chronic pain which does not respond to high levels of analgesia, despite input from pain specialists |
CASE STUDY – PRIORITY
Mr. X suffers severe, chronic pain in the left side of his head and body following a CVA. He is rarely, if ever, pain free and his symptoms are having a severe impact on his health and wellbeing. He is unable to sleep for any length of time and has lost 2 stones in weight as the pain affects his appetite and ability to chew his food. He is now taking a liquid diet but remains nutritionally at risk.
Mr. X is under the care of the Pain Clinic and has trailed a number of neuropathic analgesics, as well as PRN opioids for breakthrough pain. Unfortunately, none of these have been effective and he remains in severe, unrelenting pain.
Mr. X will be seen again by the Pain Consultant and further changes to his medication regime are expected. In the meantime, staff try to comfort and distract Mr. X, although this is of very limited benefit.
Mr. X presents with a ‘PRIORITY’ level of need as he experiences unremitting and overwhelming pain despite all efforts to control pain effectively.
We hope this has helped you to understand the last three descriptors in the Drug Therapies & Medications: Symptom Control domain. Don’t miss the next part of this series, Altered States of Consciousness, coming very soon!
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today. If you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 support page.
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